The neck

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The neck
THE HISTORY AND EXAMINATION OF
SWELLINGS IN THE NECK
with the symptoms of distant metastases such as
general malaise and loss of weight.
The majority of surgical conditions which arise in
the neck present as a swelling. Taking the history
and performing the physical examination should
follow the standard pattern, but there are some
important features that deserve special attention.
The examination of swellings in the neck
The history of swellings in the neck
Because the commonest cause of a swelling in the
neck is an enlarged lymph gland, and because the
commonest causes of enlarged lymph glands are
infection and secondary tumour deposits, you must
remember to ask about symptoms which might
help you identify the cause of the swelling.
Systemic illness
Symptoms such as general malaise, fever and rigors
and contact with people with infectious diseases
may indicate an infective cause of the swelling.
Loss of appetite, loss of weight, pulmonary, alimentary or skeletal symptoms may suggest the site
of a neoplasm.
Irritation of the skin associated with enlarged
cervical lymph glands is often seen with lymphoma.
Site
It is essential to define the site of a lump in the neck.
The neck is divided into two triangles. The anterior triangle is bounded by the anterior border of
the sternomastoid muscle, the lower edge of the jaw
and the mid-line. In clinical practice, the structures
deep to the sternomastoid muscle are considered to
be inside the anterior triangle.
The upper part of the anterior triangle, below
the jaw but above the digastric muscle, is sometimes
called the digastric or submandibular triangle.
The posterior triangle is bounded by the posterior border of the sternomastoid muscle, the anterior edge of the trapezius muscle and the clavicle.
To define the triangles it is necessary to get the
patient to tense the neck muscles.
■
The sternomastoid muscle is made to contract
by putting your hand under the patient’s chin
Head and neck symptoms
Ask about: pain in the mouth, sore throats or ulceration; nasal discharge, pain or blockage of the airway; pain in the throat, dysphagia, changes in the
voice and difficulty with breathing; and lumps or
ulcers on the skin of the head and face that have
changed size or begun to bleed.
The skin, mouth, nose, larynx and pharynx are
common sites for neoplasms, and although head
and neck cancers commonly present with metastases
in lymph glands, they are not usually associated
Posterior
triangle
FIG 11.1 The anatomical triangles of the neck.
Anterior
triangle
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Cervical lymphadenopathy and other neck swellings
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and asking them to nod their head against the
resistance of your hand. This tightens both
sternomastoids.
The trapezius muscle is made to contract by
asking the patient to shrug (elevate) their
shoulders against resistance.
Relation to muscles
Always feel lumps in the neck with the muscles
relaxed and then with them contracted. If the lump
is deep to a muscle, it will become impalpable when
the muscle contracts.
Relation to the trachea
The diagnosis of lymphadenopathy caused by
systemic illnesses such as glandular fever, toxoplasmosis and sarcoidosis depends upon finding lymphadenopathy elsewhere, other evidence of the underlying
disease, and special blood tests.
Non-specific cervical inflammatory
lymphadenopathy
Non-specific reactive lymphoid hyperplasia can follow any inflammatory process or be associated with
skin conditions, particularly of the scalp, when it
is termed dermatopathic lymphadenopathy. However, non-specific inflammatory lymphadenopathy
Swellings that are fixed to the trachea will move when
the trachea moves. The trachea is pulled upwards
during swallowing. Assess the relationship to the
trachea of every lump in the neck by watching to see
if it moves with the trachea during swallowing.
Relation to the hyoid bone
The hyoid bone moves only slightly during swallowing, but ascends when the tongue is protruded. Ask
the patient to open their mouth. When the jaw is
still, ask them to protrude their tongue. If the
swelling in the neck moves as the tongue protrudes,
it must be fixed to the hyoid bone.
CERVICAL LYMPHADENOPATHY AND
OTHER NECK SWELLINGS
Causes of cervical lymph gland
enlargement
Enlargement of the cervical lymph glands is the
most common cause of a swelling in the neck. Even
when only one gland is palpable, the adjacent glands
are invariably diseased.
The four main causes of cervical lymph gland
enlargement are as follows.
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■
■
■
Infection: non-specific tonsillitis, glandular
fever, toxoplasmosis, tuberculosis, cat scratch
fever.
Metastatic tumour from the head, neck, chest
and abdomen.
Primary reticuloses: lymphoma,
lymphosarcoma, reticulosarcoma.
Sarcoidosis.
Suboccipital
Posterior
triangle
Deep
cervical
Upper
Middle
Lower
Supraclavicular
FIG 11.2 The anatomy of the cervical lymph glands.
Revision panel 11.1
Causes of cervical lymphadenopathy
Infection
Non-specific
Glandular fever
Tuberculosis
Syphilis
Toxoplasmosis
Cat-scratch fever (Rochalimaea henselae)
Metastatic tumour
From head, neck, chest and abdomen
Primary reticuloses
Lymphoma
Lymphosarcoma
Reticulosarcoma
Sarcoidosis
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commonly follows recurrent bouts of tonsillitis,
especially if the attacks have been treated inadequately. The upper deep cervical glands are most
often affected.
In a healthy child, small normal lymph glands are
often palpable, especially in the posterior triangle.
History
Age When associated with tonsillitis, the majority
of patients are below the age of 10 years. Other reactive conditions can occur at any age.
Symptoms The common presenting symptom is a
painful lump just below the angle of the jaw.
The severity of the pain varies. It is usually a discomfort, which becomes acute when the patient has
a sore throat.
The lump may be large enough to be visible or
felt by the child’s parent when washing the neck.
The child may snore at night, have difficulty in
breathing, have nasal speech because of tonsillar
and adenoid hyperplasia, and suffer from recurrent
chest infections.
Cause The child and the parents frequently appreci-
ate the relationship between the appearance of the
lump and an episode of tonsillitis.
Systemic effects When the lump is tender the patient
often feels ill, has a sore throat and pyrexia and does
not want to eat.
Recurrent severe episodes can cause loss of
weight and slow down the rate of growth and body
maturation.
Social history Recurrent sore throats and upper
respiratory tract infections are more common in
‘Tonsillar’
lymph gland
malnurtured children living in substandard, cold,
damp houses.
Examination
Position Lymph from the tonsils drains to the upper
deep cervical lymph glands. The gland just below
and deep to the angle of the mandible is often called
the tonsillar gland. This gland and those just below
it are likely to be enlarged.
Tenderness If the infection is active, the enlarged
glands will be tender.
Shape and size The tonsillar gland is usually spher-
ical and approximately 1–2 cm in diameter. It is
rarely bigger than this. The glands below it are usually smaller, even when inflamed.
Composition and relations Each gland is firm in consistence, solid and discrete, not fixed but not very mobile.
Local tissues The tonsils are likely to be enlarged and
hyperaemic. Pus may be seen exuding from the surface crypts.
The glands on the other side of the neck are often
just as large but may not have been noticed by the
parents.
General examination Look for the presence of enlarged
lymph glands elsewhere. None should be enlarged.
Recurrent chest infections may have damaged
the lungs – look for collapsed lobes, bronchiectasis
and lung abscess. However, these are rare complications nowadays.
Tuberculous cervical lymphadenitis and
abscess
The human tubercle bacillus can enter the body via
the tonsils, and from there move to the cervical lymph
glands. The upper deep cervical glands are most often
affected. There is no generalized infection, so there
is little systemic disturbance of health. Infection
with bovine tuberculosis ceased in the UK when the
control and testing of dairy cattle was introduced.
History
FIG 11.3 The site of the ‘tonsillar’ lymph gland.
Age and ethnic groups Tuberculous lymphadenitis
is common in children and young adults, and in
the elderly. In the UK the incidence in the young
has diminished since the introduction of Bacilli
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Cervical lymphadenopathy and other neck swellings
Calmette–Guerin (BCG) vaccination, mass radiography screening and the discovery of effective antituberculosis antibiotics; but the prevalence of cervical
lymph gland enlargement caused by anonymous
mycobacteria is increasing. In the UK, tuberculous
lymphadenitis is found most often in young immigrant adults.
Symptoms The patient complains of a lump in the
neck. This appears gradually, sometimes with, sometimes without, pain.
The pain can be intense if the glands grow rapidly and necrose.
Systemic symptoms are unusual in the young,
but the elderly sometimes have anorexia and slight
weight loss.
If the glands break down into an abscess, the
swelling increases in size, becomes more painful
and the patient notices discolouration of the overlying skin.
When the glands are very painful, neck movements and swallowing may be painful.
Previous history Elderly patients often have a history
of swollen neck glands when young – sometimes
treated at that time by surgical excision.
Immunization Ask whether the patient has been vac-
cinated with BCG.
Family history Check that no one in the family has
had tuberculosis.
Social history Tuberculosis is more common in the
poor and socially underprivileged.
Examination
The signs of tuberculous lymphadenitis
Position The upper and middle deep cervical glands
are most often involved.
Temperature The mass of glands does not feel hot.
Tenderness Although the temperature of the skin is
normal and the glands are often slightly tender, pain
and tenderness are not prominent features of tuberculous lymphadenitis.
Colour If there is no abscess present, the overlying
skin should look normal.
FIG 11.4 Enlargement of the upper deep cervical lymph
glands caused by tuberculosis.
Shape, size and consistence In the early stages, the
glands are firm, discrete and between 1 and 2 cm in
diameter.
As caseation increases and the glands necrose,
the infection spreads beyond the capsules of the
glands. This makes the lumps enlarge and coalesce.
A typical patch of tuberculous lymphadenitis is an
indistinct, firm mass of glands which occupies the
upper half of the deep cervical lymph chain, partly
beneath and partly in front of the sternomastoid
muscle.
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The glands are commonly described as matted
together, but there may be some discrete glands
above or below the matted mass.
Local tissues Other cervical lymph glands may be
palpable. The tonsils and the other tissues in the
neck should be normal.
The signs of a tuberculous abscess
When an infected lymph gland caseates and turns
into pus, it becomes, by definition, an abscess. The
natural tendency of an abscess is to weaken the overlying tissues until it bursts through them, ultimately
to reach and burst through the skin. This is known
as pointing. At the stage when a tuberculous abscess
Enlarged discrete
glands
'Matted' glands
The development of a ‘collar-stud’ abscess.
A large tuberculous ‘collar-stud’ abscess.
FIG 11.5 THE TUBERCULOUS ABSCESS.
has burst through the deep cervical fascia into the
subcutaneous tissues, it has two compartments, one
on either side of the deep fascia, connected by a small
central track. This is called a collar-stud abscess.
Position Because a tuberculous abscess forms in
tuberculous lymph glands, it is most often found in
the upper half of the neck.
Colour When the pus reaches the subcutaneous tissues, the overlying skin turns reddish-purple.
Temperature The skin temperature is normal because
the process of caseation and pus formation is slow
and does not stimulate excessive hyperaemia –
hence the name cold abscess.
Abscess forms in the
centre of the glands
Abscess bursts
through the deep
fascia and becomes
'collar-stud' in shape
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Cervical lymphadenopathy and other neck swellings
Tenderness The mass is tender, sometimes exquis-
General examination When the patient has tuberculous
itely so if the abscess is tense.
lymphadenitis there are often no systemic abnormalities; but when a tuberculous abscess develops there
may be tachycardia, pyrexia, anorexia and general
malaise.
There may be signs of tuberculosis in the lungs,
in other lymph glands and in the urinary tract.
Shape The deep part of the abscess tends to be
sausage shaped, with its long axis parallel to the
front edge of the sternomastoid muscle. The superficial pocket of the abscess is usually lower than the
deep part.
Size Most tuberculous abscesses are 3–5 cm across,
but they can be much larger.
Surface The surface is irregular and indistinct.
Edge The edges are moderately well defined if the
abscess is tense, but you will not be able to feel a definite surface or edge if the pocket of pus is lax.
Composition The abscess feels firm and rubbery and
if there is sufficient pus present, it will fluctuate.
This latter sign cannot be elicited if the abscess is
small and deep to the sternomastoid muscle.
The subcutaneous part of a collar-stud abscess
should be clearly fluctuant, but it is not usually possible to reduce the superficial pocket of pus into the
deep pocket.
Relations The original abscess is deep to the deep
fascia, partly under the sternomastoid muscle, and
fixed to surrounding structures. The superficial part
of a collar-stud abscess is immediately below the
skin and becomes more prominent when the sternomastoid muscle is contracted. If spontaneous discharge occurs, a chronic sinus may form. Tuberculous
sinuses are characterized by minimal erythema and
lack of pain, unless secondarily infected.
The other lymph glands in the neck near the
abscess may be enlarged.
Carcinomatous lymph glands
Metastatic deposits of cancer cells in the cervical
lymph glands are the commonest cause of cervical
lymphadenopathy in adults.
The primary cancer is most often in the buccal
cavity (tongue, lips and mucous membrane) and larynx, but every possible primary site must be examined when cervical glands are thought to be enlarged
by secondary deposits.
History
Age Most head and neck cancers occur in patients
over the age of 50. Most patients presenting with
metastatic deposits in their cervical lymph glands
are between 55 and 65 years.
The exception is papillary carcinoma of the thyroid, which occurs in children and young adults.
FIG 11.7 This patient presented with hard, enlarged lymph
FIG 11.6 A chronic tuberculous sinus that has become
secondarily infected.
glands in the neck. The primary lesion was the insignificant
mole above his right eyebrow.
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Sex Most of the head and neck cancers are more
common in men than in women.
Local symptoms The patient complains of a painless
lump in the neck, which they have seen or felt by
chance.
It is uncommon for carcinomatous glands to be
tender or to become so large that they interfere with
neck movements before being noticed.
The lump grows slowly, and new lumps may
appear.
General symptoms The patient may have symptoms
from a primary lesion in the head or neck, such as a
sore tongue or a hoarse voice. If the primary is in
the chest, they may have a cough or haemoptysis; if
it is in the abdomen, they may have dyspepsia or
abdominal pain.
Generally speaking, head and neck cancers do
not cause anorexia and weight loss, whereas cancers
in the lungs and intra-abdominal organs do.
Examination
Site The site of the affected glands gives a crude
indication of the site of the primary. Lesions above
the hyoid bone drain to the upper deep cervical
glands. The larynx and thyroid drain to the middle
and lower deep cervical glands. An enlarged supraclavicular lymph gland commonly indicates intraabdominal or thoracic disease. When enlarged by
metastases, this gland is called Virchow’s gland; its
presence is Troisier’s sign.
Colour The overlying skin is a normal colour unless
the mass is so large that it stretches or infiltrates the
skin, which makes it pale or blotchy red.
Temperature The skin temperature will be normal
unless the tumour is very vascular.
Tenderness Glands containing secondary deposits
are not tender.
Shape and size Glands containing metastases vary in
size and shape. Both features depend upon the
amount of tumour within them and the rate of its
growth. At first the glands are smooth, discrete and
a variety of sizes. As they grow, they may coalesce
into one large mass.
Composition Glands containing tumour are hard,
often stony hard. Rarely, a very vascular tumour
deposit will be soft, pulsatile and compressible.
FIG 11.8 Secondary malignant deposits in the skin of the neck.
Relations The glands are tethered to the surrounding structures, so they can usually be moved in a
transverse direction, but not vertically.
Their relation to the sternomastoid muscle varies
according to the group to which they belong. Secondary cancer is more common in the glands of the
anterior than the posterior triangle. These glands are
deep to the anterior edge of the sternomastoid.
If the tumour spreads beyond the capsules of the
glands, the mass becomes completely fixed.
Local tissues The overlying skin and muscle may be
infiltrated with tumour, in which case the tumour
must be distinguished from secondary deposits
actually in the skin.
Lymph drainage Other lymph glands on the pathway
between the primary lesion and the gland complained of by the patient, and beyond it, may be
enlarged.
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Cervical lymphadenopathy and other neck swellings
General examination Examine all the sites which might
contain the primary lesion, in particular:
■
■
■
■
■
■
■
■
1
the skin of the scalp, the ear and the external
auditory meatus,
the lips, tongue, buccal mucous membrane and
tonsils,
the nose, maxillary antra and nasopharynx,
the thyroid gland,
the skin of the upper limb,
the breasts,
the lungs,
the stomach, pancreas, ovaries and testes.
The symptoms and signs of malignant disease
originating in these organs are discussed in the appropriate chapters.
Some of this examination requires special
instruments, for example a head mirror and light
and a laryngeal mirror.
Primary neoplasms of the lymph glands
(Reticuloses, lymphoma)
The most common primary tumour of lymphoid
tissue is the malignant lymphoma. There are many
histological varieties of lymphoma, but they are
often collectively and loosely divided into Hodgkin’s
and non-Hodgkin’s lymphoma.
History
Age The reticuloses are common in children and
young adults.
Sex Males are affected more often than females.
Symptoms The most common presenting symptom
is a painless lump in the neck, which is noticed by
chance and grows slowly.
Malaise, weight loss and pallor are common
symptoms.
Itching of the skin (pruritus) is an unexplained
but distinctive complaint.
There may be fever with rigors, occurring in a
periodic fashion (Pel–Ebstein fever).
Lymphomatous infiltration of the skeleton may
cause pains in the bones, and there may be abdominal pain after drinking alcohol.
If there are large masses of lymph glands in the
mediastinum, they may occlude the superior vena
2
3 4
5
6
7
8
9
10
11
1. Scalp (sometimes via the preauricular node)
Parotid gland
Upper face
Ear
2. Maxillary antrum and other air sinuses
Nasal cavity and nasopharynx
3. Tongue
Buccal mucosa
Floor of mouth
Mandible
4. Lips
5. Tonsil
Base of tongue
Oropharynx
6. Submandibular gland
Skin of neck
7. Larynx and laryngopharynx
8. Thyroid
Upper oesophagus
9. Upper limb and both sides of the chest wall
10. Breast
11. Lungs, stomach and all the viscera
FIG 11.9 Sites of primary neoplasms that metastasize to the
cervical lymph glands.
cava, causing venous congestion in the neck and
the development of collateral veins across the chest
wall.
Large masses in the abdomen can obstruct the
inferior vena cava and cause oedema of both legs.
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The neck
FIG 11.11 Cutaneous deposits of lymphoma.
FIG 11.10 Bilateral cervical lymphadenopathy caused by
Hodgkin’s lymphoma.
tuberculosis, in which the lymph glands become
matted and indistinct.
Consistence Glands infiltrated by lymphoma are
Examination
solid and rubbery in consistence.
Site Any of the cervical lymph glands can be
Relations Although tethered to nearby structures,
these glands can usually be moved from side to side
and rarely become completely fixed.
affected. Lymphoma is one of the few conditions,
apart from infection, that often causes lymphadenopathy in the posterior triangle.
Local tissues The surrounding tissues should be
Tenderness The glands are not tender.
normal.
Shape, size and surface The lymph glands in Hodgkin’s
disease are ovoid, smooth and discrete.
It is possible to define individual glands even
when they become large. This is the opposite to
General examination Other groups of lymph glands
Revision panel 11.2
Plan of examination for source of secondary
cervical lymphadenopathy
(Start at the top and work downwards.)
Examine the skin of the scalp, face, ears
and neck.
Look in the nose.
Look in the mouth at the tongue, gums, mucosa
and tonsils.
Palpate the parotid, submandibular and thyroid
glands.
Examine the arms and the chest wall – including
the breast.
Examine the abdomen and genitalia.
Transilluminate the air sinsuses.
Examine the nasopharynx and larynx with mirrors.
may be enlarged. The liver and spleen may be palpable. The patient is often anaemic and may be
jaundiced.
Spread to the skin produces elevated, reddened,
scaly patches of skin known as mycosis fungoides.
Branchial cyst
A branchial cyst is a remnant of a branchial cleft,
usually the second cleft. It is therefore lined with
squamous epithelium, but there are also patches of
lymphoid tissue in the wall which are connected
with the other lymph tissue in the neck and which
can become infected.
History
Age Although these cysts are present at birth, they
may not distend and cause symptoms until adult
life. The majority present between the ages of
15 and 25 years, but a number appear in the 40s
and 50s.
Sex Males and females are equally affected.
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Cervical lymphadenopathy and other neck swellings
A branchial cyst
appears from
beneath the upper
third of the sternomastoid muscle
FIG 11.12 The site of a branchial cyst.
FIG 11.14 A large branchial cyst which had become painful.
This commonly follows recurrent bouts of tonsillitis,
especially if the infection has been treated inadequately.
bulges forwards. Very rarely, the cyst can bulge
backwards behind the muscle.
Colour and tenderness The overlying skin may be red-
dened and the lump may be tender if the cyst is
inflamed.
FIG 11.13 A branchial cyst which presented in adult life. The
back of the swelling is clearly deep to the sternomastoid
muscle.
Symptoms The common presenting complaint is a
painless swelling in the upper lateral part of the neck.
The lump may be painful when it first appears and
later cause attacks of pain associated with an increase
in the size of the swelling. The pain is usually caused
by infection in the lymphoid tissue in the cyst wall.
A severe throbbing pain, exacerbated by moving
the neck and opening the mouth, develops if the
contents of the cyst become infected and purulent.
Shape The cyst is usually ovoid, with its long axis
running forwards and downwards.
Size Most branchial cysts are between 5 and 10 cm
long.
Surface Their surface is smooth and the edge distinct.
Composition The consistence varies with the tension
Examination
of the cyst. Most cysts are hard, but a lax cyst feels
soft. They are dull to percussion.
The lump fluctuates. This sign is not always easy
to elicit, especially if the cyst is small and the sternomastoid muscle thick.
The lump is usually opaque because it contains
desquamated epithelial cells that make its contents
thick and white. Sometimes the fluid is golden yellow and shimmers with fat globules and cholesterol
crystals secreted by the sebaceous glands in the epithelial lining. Such cysts may transilluminate.
The cyst cannot be reduced or compressed.
Position A branchial cyst lies behind the anterior edge
of the upper third of the sternomastoid muscle, and
Relations It is important to ascertain that the bulk
of the mass is deep to the upper part of the
General effects These cysts have no systemic effects
and are not associated with any other congenital
abnormality.
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sternomastoid muscle. It is not very mobile because
it is closely tethered to the surrounding structures.
the carotid artery by the tumour is a very slow
process.
Lymph drainage The local deep cervical lymph glands
should not be enlarged. If they are palpable, you
should reconsider your diagnosis in favour of an
inflammatory process such as a tuberculous abscess
rather than a branchial cyst. The other cystic lesions
that are often operated upon as presumed branchial
cysts are often secondary cystic lymph gland deposits
from a papillary carcinoma of the thyroid.
Development The lump grows so slowly that many
patients ignore it for many years.
Local tissues The local tissues should be normal.
Position The carotid bifurcation is at, or just below,
the level of the hyoid bone. Carotid body tumours
If the cyst has turned into an abscess, the surrounding tissues will be oedematous and the skin
hot and red.
Branchial fistula (or sinus)
This is a rare congenital abnormality. It is the remnant of a branchial cleft, usually the second cleft,
which has not closed off.
The patient complains of a small dimple in the
skin at the junction of the middle and the lower
third of the anterior edge of the sternomastoid
muscle, that discharges clear mucus, and sometimes
becomes swollen and painful and discharges pus.
When the whole branchial cleft stays patent, the
fistula connects the skin with the oropharynx, just
behind the tonsil. In most cases the upper end is
obliterated and the track should really be called a
branchial sinus.
Swallowing accentuates the openings on the skin.
Multiplicity Carotid body tumours may be bilateral.
Examination
Always be especially gentle when palpating a lump
close to the bifurcation of the carotid artery. Pressure in this area can induce a vasovagal attack.
A carotid body
tumour should be
level with the
hyoid cartilage
The external
carotid artery may
cross the surface
of the tumour
FIG 11.15 The site of a carotid body tumour.
Carotid body tumour
This is a rare tumour of the chemoreceptor tissue
in the carotid body. It is therefore a chemodectoma.
It is usually benign, but can become quite large and,
occasionally, malignant.
History
Age Chemodectomata commonly appear in patients
between the ages of 40 and 60 years.
Symptoms The common presentation is a painless,
slowly growing lump. The patient may notice that
the lump pulsates, and may also suffer from symptoms of transient cerebral ischaemia (blackouts,
transient paralysis or paraesthesia). These symptoms
are unusual because the increasing compression of
FIG 11.16 A carotid body tumour. Note that the visible mass is
lower than that of a branchial cyst (see Fig. 11.13) but
indistinguishable on inspection from an enlarged cervical
lymph gland. Most carotid body tumours are initially mistaken
for enlarged lymph glands.
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Cervical lymphadenopathy and other neck swellings
are therefore found in the upper part of the anterior
triangle of the neck, level with the hyoid bone and
beneath the anterior edge of the sternomastoid
muscle.
Tenderness, colour and temperature These tumours are
not tender or hot, and the overlying skin should be
normal.
Shape The lump is initially spherical but, as it
grows, it becomes irregular in shape, often narrower
at its lower end, where it is caught at the bifurcation
of the common carotid artery.
Size Carotid body tumours may vary from 2–3 cm
to 10 cm in diameter.
Composition The majority of these tumours are solid
and hard. They are dull to percussion and do not
fluctuate. They are often called potato tumours
because of their consistence and shape.
Sometimes these tumours pulsate. This is either
a transmitted pulsation from the adjacent carotid
artery, or a palpable external carotid artery running
over the superficial aspect of the lump, or a true
expansile pulsation from a soft or very vascular
tumour.
It is surprising that in spite of their vascularity
most of these tumours are hard. Those which are
soft and very vascular not only have an expansile
pulsation, but can also be compressed.
Relations The lump is deep to the cervical fascia and
beneath the anterior edge of the sternomastoid
muscle.
The common carotid artery can be felt below the
mass, and the external carotid artery may pass over
its superficial surface. Without this close relationship to the arteries, this tumour is indistinguishable
from an enlarged lymph gland.
Because of their intimate relationship with the
carotid arteries, these tumours can be moved from
side to side but not up and down.
Cystic hygroma
(Lymph cyst, lymphocele, lymphangioma)
A cystic hygroma is a congenital collection of lymphatic sacs which contain clear, colourless lymph.
They are probably derived from clusters of lymph
channels that failed, during intra-uterine development, to connect with and become normal lymphatic
pathways. Lymph cysts commonly occur near the root
of the arm and the leg (i.e. in the anatomical junction between the limbs and head and the trunk).
History
Age The majority of cystic hygromata present at
birth or within the first few years of life, but they
occasionally stay empty until infection or trauma in
adult life causes them to fill up and become visible.
Occasionally large lymphoceles can be seen in elderly patients.
Symptoms The only symptom is the complaint about
the lump, but the parents of an affected child are
usually more concerned about the disfigurement
caused by the cyst.
Family history This condition is not familial.
Examination
Position Cystic hygromata are commonly found
around the base of the neck, usually in the posterior
The cystic hygroma
is commonly found
in the subcutaneous
tissues at the base
of the posterior
triangle
It is brilliantly
translucent
FIG 11.17 A large carotid body tumour. A very large, firm,
bosselated carotid body tumour – hence the term ‘potato
tumour’.
FIG 11.18 The site of a cystic hygroma.
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The neck
Temperature and tenderness They are not hot or ten-
der, and the overlying skin is normal.
Shape A cystic hygroma is a mixture of soft unilocular and multilocular cysts, so the whole mass looks
lobulated and flattened.
Size The small cysts are a few centimetres across.
Large cysts can extend over the whole of one side of
the neck.
Surface If the cysts are close to the skin, it may not
be possible to feel a distinct surface. Deep cysts feel
smooth, but because they are lax their edges are
often indistinct.
Composition Cystic hygromata are soft and dull to
percussion. They fluctuate easily but, because they
are close to the skin and contain clear fluid, their
distinctive physical sign is a brilliant translucence.
Large cysts will conduct a fluid thrill, and in some
multilocular swellings the fluid in one loculus can
be compressed into another.
They cannot be reduced.
FIG 11.19 TWO EXAMPLES OF CYSTIC HYGROMA. In a very
young child – the common age of presentation, and in a
young adult.
Relations Cystic hygromata develop in the subcutaneous tissues. Thus they are superficial to the neck
muscles and close to the skin but are rarely fixed to
the skin. However, it is essential to perform a thorough examination of the oropharynx, as a cyst in the
posterior triangle may extend deeply beneath the sternomastoid muscle into the retropharyngeal space.
Lymph glands The local lymph glands should not be
enlarged and, as the lymph drainage of the tissues
around the cyst is normal, there is no lymphoedema. If there is associated lymphadenopathy,
reconsider the diagnosis, as cystic nodal metastases
of papillary thyroid carcinoma can present as large,
painless cystic swellings in the neck.
Local tissues The local tissues are normal.
Pharyngeal pouch
FIG 11.20 A large lymphocele in an elderly lady.
triangle, but they can be very big and occupy the
whole of the subcutaneous tissue of one side of
the neck.
A pharyngeal pouch is a pulsion diverticulum of the
pharynx through the gap between the horizontal fibres
of the cricopharyngeus below and the lowermost
oblique fibres of the inferior constrictor muscle
above. If swallowing is uncoordinated so that the
sphincter-like fibres of the cricopharyngeus do not
relax, the weak unsupported area just above these
fibres (known as Killian’s dehiscence) bulges out.
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Cervical lymphadenopathy and other neck swellings
Oblique fibres
of inferior constrictor
(thyropharyngeus)
Dehiscence
of Killian
Transverse fibres
of inferior constrictor
(cricopharyngeus)
Pharyngeal
pouch
Oesophagus
Oesophagus
compressed
by pouch
Normal
Pouch
A pharyngeal pouch
rarely causes a
detectable swelling
If it does, the swelling
is behind the
sternomastoid muscle
FIG 11.21 The anatomy of a
pharyngeal pouch.
By the time these symptoms become severe, the
patient may have noticed a swelling in the neck,
and find that pressure on the swelling causes gurgling
sounds and regurgitation. The swelling changes in
size and often disappears.
If the dysphagia continues, the patient may
become malnourished and lose weight.
Examination
Position In most patients there is no palpable swelling,
FIG 11.22 The site of a pharyngeal pouch.
Eventually the bulge grows into a sac, which hangs
down and presses against the side of the oesophagus.
History
Age Pharyngeal pouches appear in middle and
old age.
Sex They are more common in men than in women.
Symptoms Patients often have a long history of halitosis and recurrent sore throats before noticing the
common presenting symptom of regurgitation of
froth and food. The regurgitated food is undigested
and comes up into the mouth at any time. There is
no bile or acid taste to it.
Regurgitation at night causes bouts of coughing
and choking, and if pieces of food are inhaled, a
lung abscess may develop.
As the pouch grows, it presses on the oesophagus
and causes dysphagia. Patients can sometimes swallow their first few mouthfuls of food (until the pouch
is full), but thereafter have difficulty in swallowing.
but when a swelling caused by a pharyngeal pouch
is apparent, it appears behind the sternomastoid
muscle, below the level of the thyroid cartilage.
Shape Its shape is indistinct because only part of
its surface is palpable. It feels like a bulging deep
structure.
Size Most pouches only cause a swelling of 5–10 cm
diameter. The pouch is not palpable when it is
smaller, so many patients have symptoms but no
abnormal physical signs.
Surface and edge The surface is smooth, but the edge
is not palpable.
Composition The lump is soft and sometimes
indentable. It is dull to percussion and does not
fluctuate or transilluminate.
It can be compressed and sometimes emptied.
Compression may cause regurgitation. Although
the mass may disappear with compression, not to
return until the patient eats again, it cannot be said
to have been ‘reduced’ according to the usual meaning of the word.
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The neck
A 'sternomastoid
tumour' is an area
of oedema and
necrosis in the
lower third of the
sternomastoid
muscle
Relations A pharyngeal pouch lies deep to the deep
fascia, behind the sternomastoid muscle, and is
fixed deeply. Its origin from a structure behind the
trachea can be appreciated during palpation, but
the neck of the pouch and its attachment to the
oesophagus cannot be felt.
It cannot be moved about in the neck.
Lymph glands The cervical lymph glands should not
be enlarged.
Local tissues The surrounding tissues feel normal.
Indeed, when the pouch is empty the whole neck
feels normal.
FIG 11.23 The site of a sternomastoid tumour.
General examination Pay special attention to the chest,
as there may be an aspiration pneumonia, collapse
of a lobe or a lung abscess.
Tenderness The lump may be tender in the first few
weeks of life.
Shape and size The swelling is fusiform, with its long
Sternomastoid ‘tumour’
(Ischaemic contracture of a segment of the
sternomastoid muscle)
This is a swelling of the middle third of the sternomastoid muscle. In neonates it consists of oedema
around an infarcted segment of the muscle, caused
by the trauma of birth. As the patient grows, the
lump disappears and the abnormal segment of
muscle becomes fibrotic and contracted.
History
Age The lump is noticed at birth or in the first few
weeks of life.
Symptoms The mother may notice the lump or that
the child keeps their head turned to one side –
torticollis. Attempts to turn the head straight may
cause pain or distress.
If the muscle is not extensively damaged, the
swelling slowly subsides, the muscle spasm relaxes
and the torticollis disappears. If the muscle damage
becomes an area of permanent fibrosis, the twist
and tilt of the head to one side becomes more
noticeable as the child grows.
Examination
The lump
Position The swelling lies in the middle of the sternomastoid muscle (i.e. in the middle third of the
neck on the antero-lateral surface).
axis along the line of the sternomastoid muscle. It is
usually 1–2 cm across.
Surface The surface is smooth.
Edge The anterior and posterior edges of the lump
are distinct but the superior and inferior edges,
where the lump becomes continuous with normal
muscle, are indistinct.
Composition At first the lump is firm and solid and
easy to feel, but as it gradually becomes harder it
begins to shrink and may become impalpable.
Surrounding structures and local lymph glands These
should be normal.
The neck
Examine the movements of the neck. As the child
is too young to obey commands, you must watch
how they move their head when lying in their
cot, and then manipulate the head and neck very
gently.
The sternomastoid muscles rotate and tilt the
head. Contraction of the left sternomastoid turns
the head towards the right, but tilts the head to the
left. Both these deformities may be present. Forced
movement to correct the deformity may cause pain
and be resisted by the child.
Apart from the restriction of movement caused
by spasm of the sternomastoid muscle, the neck
movements should be normal.
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Cervical lymphadenopathy and other neck swellings
FIG 11.25 An infantile torticollis caused by ischaemia of the
sternomastoid muscle.
FIG 11.24 A localized swollen segment of sternomastoid with
a slight torticollis in an older child, caused by ischaemia and
fibrosis of the muscle after birth. A typical sternomastoid
‘tumour’.
The eyes
Look at the eyes and watch their movements to detect
any squint. Torticollis can be a means of correcting a
squint. Move the head into a vertical and central
position and watch the eyes. If the torticollis is secondary to a squint and not a sternomastoid tumour,
the squint will appear as the head is straightened.
The head
An uncorrected torticollis may affect the growth of
the facial bones and cause facial asymmetry.
In adults, recent onset torticillis usually just represents muscle spasm.
Cervical rib
Although the cervical rib can cause serious neurological and vascular symptoms in the upper arm,
FIG 11.26 An adult form of torticollis caused by muscular
spasm.
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The neck
clinical examination of the neck does not usually
reveal any abnormalities. The abnormal rib is usually detected with an X-ray. Sometimes there is a
fullness at the root of the neck, but it is rarely distinct enough to justify a firm clinical diagnosis of
cervical rib. Occasionally it can be associated with
aneurysmal change in the subclavian artery.
The common neurological symptoms caused by
a cervical rib are pain in the C8 and T1 dermatomes,
and wasting and weakness of the small muscles in
the hand. Vascular symptoms such as Raynaud’s
phenomenon, trophic changes, even rest pain and
gangrene, may occur but are uncommon.
FIG 11.27 An X-ray demonstrating a cervical rib.
Thyroglossal cyst
The thyroid gland develops from the lower portion of
the thyroglossal duct, which begins at the foramen
caecum at the base of the tongue and passes down
to the pyramidal lobe of the isthmus of the thyroid
gland. If a portion of this duct remains patent, it can
form a thyroglossal cyst.
Theoretically, thyroglossal cysts can occur anywhere between the base of the tongue and the isthmus of the thyroid gland, but they are commonly
found in two sites: between the isthmus of the thyroid gland and the hyoid bone, and just above the
hyoid bone. Thyroglossal cysts within the tongue
and in the floor of the mouth are rare.
A cervical rib
rarely causes a
visible swelling
It may cause a
subclavian artery
aneurysm
FIG 11.28 The site of a cervical rib.
Suprahyoid
History
Age Thyroglossal cysts appear at any age, but the
majority are seen in patients between 15 and 30
years old.
Subhyoid
Sex They are more common in women than in men.
Pretracheal
Symptoms The commonest symptom is a painless
lump in a prominent and noticeable part of the neck.
Pain, tenderness and an increase in size occur only
if the cyst becomes infected.
Duration of symptoms The lump may have been present for many years before an increase in its size
causes the patient to complain.
Systemic symptoms There are no systemic symptoms
associated with this condition.
FIG 11.29 The sites of a thyroglossal cyst.
Examination
Position Thyroglossal cysts lie close to the mid-line,
somewhere between the chin and second tracheal
ring. In the fetus the thyroglossal duct is in the
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Cervical lymphadenopathy and other neck swellings
Composition Thyroglossal cysts have a firm or hard
consistence, depending upon the tension within the
cyst. Some cysts are too tense and others too small
to fluctuate, but the majority of thyroglossal cysts
are between these extremes and fluctuate with ease.
Some cysts transilluminate but many do not, either
because the contents have become thickened by
desquamated epithelial cells or the debris of past
infection, or because they are too small.
Revision panel 11.3
A scheme for the diagnosis of swellings
in the neck (deep to the deep fascia)
Subhyoid cyst.
Pretracheal cyst.
FIG 11.30 TWO THYROGLOSSAL CYSTS.
mid-line, but when a cyst forms in adult life it often
slips to one side of the mid-line, especially if it develops in front of the thyroid cartilage.
Colour, temperature and tenderness If the cyst is infected,
the overlying skin will be red, hot and tender. When
there is no infection, the overlying skin is normal.
Shape and surface Thyroglossal cysts are spherical
and smooth, with a clearly defined edge.
Size They vary from 0.5 to 5 cm in diameter. Because
a lump in the front of the neck is so noticeable,
patients often complain of these cysts when they are
very small.
After your examination you should be able to
answer four critical questions:
1. Is there one or more than one lump?
2. Where is the lump?
3. Is it solid or cystic?
4. Does it move with swallowing?
Multiple lumps are invariably lymph glands
A single lump
In the anterior triangle that does not move with
swallowing
Solid:
■ a lymph gland
■ carotid body tumour
Cystic:
■ cold abscess
■ branchial cyst
In the posterior triangle that does not move with
swallowing
Solid:
■ a lymph gland
Cystic:
■ cystic hygroma
■ pharyngeal pouch
■ occasionally a secondary deposit of a
papillary thyroid carcinoma
Pulsatile:
■ subclavian aneurysm
In the anterior triangle that moves with
swallowing
Solid:
■ thyroid gland
■ thyroid isthmus lymph gland
Cystic:
■ thyroglossal cyst
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The neck
The thyroglossal duct is always closely related,
usually fixed, to the hyoid bone. When the hyoid
bone moves the cyst also moves.
The hyoid bone moves upwards when the tongue
is protruded. First, ask the patient to open their
mouth and keep the lower jaw still; next hold the
cyst with your thumb and forefinger, and then ask
the patient to protrude their tongue. If the cyst is
fixed to the hyoid bone, you will feel it tugged
upwards as the tongue goes out. This is a difficult
sign to elicit.
Do not expect to see much movement. It is easier
to feel the tugging sensation than to actually see the
movement. Although this test is diagnostic of
attachment to the hyoid cartilage, the absence of
movement does not exclude the diagnosis. Indeed,
this sign is absent from most cysts that are below the
level of the thyroid cartilage.
Lymph glands The local lymph glands should not be
enlarged unless there is secondary infection of
the cyst.
Local tissues Whenever there is an abnormality of
FIG 11.31 An infected thyroglossal cyst.
Relations Thyroglossal cysts are tethered by the remnant of the thyroglossal duct. This means that they
can be moved sideways, but not up and down.
thyroid gland development, examine the base of
the tongue for ectopic (lingual) thyroid tissue.
A lingual thyroid looks like a flattened strawberry
sitting on the base of the tongue.
THE THYROID GLAND
SYMPTOMS OF THYROID DISEASE
The thyroid gland can cause two groups of symptoms and signs: those connected with the swelling
in the neck, and those related to the endocrine activity of the gland. Therefore, in order to appreciate
fully the symptoms and signs that may be produced
by diseases of the thyroid, a clear understanding
of the physiology of the gland is essential. The history and examination should be directed towards
detecting both local and general symptoms and
signs that may be produced, either by any physical
abnormality in the configuration of the thyroid or by
any pathophysiological abnormality of its endocrine
activity.
Neck symptoms
A lump in the neck
The majority of thyroid swellings grow slowly and
painlessly. Quite often the patient will come across a
swelling coincidentally when washing, or a member
of their family or a close friend will point it out to
them. Other swellings may have been there for some
years before the patient suddenly decides to seek
advice concerning their nature and management. In a
few patients, a lump will appear suddenly and may be
painful, or a long-standing lump may enlarge quickly.
A rapid change in the size of part of the gland, or
of an existing lump, may be caused by haemorrhage
into a necrotic nodule, a fast-growing carcinoma,
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Symptoms of thyroid disease
PHYSIOLOGY OF THE THYROID GLAND.
Circulating iodine and tyrosine
Pituitary and hypothalamus
Thyroid-stimulating
hormone (TSH)
Inhibitory feedback
Active hormones
(T3 and T4)
1 Increase tissue metabolism
(by affecting the respiratory
enzymes in mitochondria)
Increased appetite
Decreased weight
Increased heat production
and oxygen consumption
2 Increase sensitivity of
β-adrenergic receptors
Tachycardia
Lid lag
Tremor
Nervousness
3 Increase tissue growth
(by increasing metabolism
and secretion of growth
hormone)
Increased growth and
early tissue maturation
The active thyroid hormones are thyroxine (tetra-iodothyronine,T4) and probably tri-iodothyronine (T3)
FIG 11.32
or subacute thyroiditis. The sudden enlargement of
a lump caused by haemorrhage is usually painful,
whereas a fast-growing anaplastic carcinoma is not
usually painful until it invades nearby structures.
A special feature of papillary and follicular carcinomata of the thyroid gland is their very slow
growth. They may exist as a lump in the neck for
many years before metastasizing. Thus the length of
Revision panel 11.4
Physiology of the thyroid gland
Changes in hormone activity can be assessed by:
■ clinical examination
■ measuring circulating tri-iodothyronine
(T3) and thyroxine (T4)
■ measuring the rate and quantity of
radioactive iodine taken up by the gland.
Hormone secretion can be suppressed by:
■ iodine, which inhibits hormone release
■ potassium perchlorate, which interferes
with iodine trapping
■ carbimazole and thiouracil, which inhibit
the iodination of tyrosine and the coupling of
tyrosines to make thyronines
■ destroying the gland surgically or with
radiotherapy.
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The neck
time that a lump has been present is no indication
as to its underlying nature.
Discomfort during swallowing
Large swellings may give the patient a tugging sensation in the neck when they swallow. This is not
true dysphagia. Thyroid swellings rarely obstruct the
oesophagus because the oesophagus is a muscular
tube that is easily stretched and pushed aside. However, because the thyroid has to be pulled upwards
with the trachea in the first stage of deglutition, an
enlarged gland can make swallowing uncomfortable,
or even difficult.
Dyspnoea
Deviation or compression of the trachea by a mass
in the thyroid may cause difficulty in breathing.
This symptom is often worse when the neck is
flexed laterally or forwards and when the patient lies
down. The whistling sound of air rushing through a
narrowed trachea is called stridor.
Pain
Pain is not a common feature of thyroid swellings.
Acute and subacute thyroiditis can present with a
painful gland, and Hashimoto’s disease often causes
an uncomfortable ache in the neck.
Anaplastic carcinoma can cause local pain and
pain referred to the ear if it infiltrates surrounding
structures.
Hoarseness
A change in the quality of the voice of a patient with
a lump in the neck is a very significant symptom
because it is probably caused by a paralysis of one
of the recurrent laryngeal nerves, which means that
the lump is likely to be malignant and infiltrating
the nerve.
Symptoms and signs of endocrine
dysfunction
Every patient with any thyroid disorder should be a
carefully questioned and examined for any symptoms or signs of endocrine dysfunction.
Symptoms and signs of thyrotoxicosis
(see also pages 299–301)
Nervous system Symptoms include nervousness,
irritability, insomnia and nervous instability, and
examination may reveal a tremor of the hands.
Occasionally a full-blown thyrotoxic psychosis may
be apparent.
Cardiovascular system Symptoms include palpita-
tions, breathlessness on exertion, swelling of the
ankles and chest pain, which may be manifest as
tachycardia, auricular fibrillation dyspnoea and
peripheral swelling.
Metabolic and alimentary systems There is an increase
in appetite but loss of weight, and sometimes a
change of bowel habit, usually diarrhoea. Proximal
muscle myopathies may occur with wasting and
weakness. The patient has a preference for cold
weather, and often complains of excessive sweating
and an intolerance of hot weather. Some women have
a change of menstruation, usually amenorrhoea.
Symptoms and signs of myxoedema
(see also pages 301–3)
There is an increase of weight, with deposition of
fat across the back of the neck and shoulders.
Symptoms also include: slow thought, speech and
action; intolerance of cold weather; loss of hair,
especially the outer third of the eyebrows; muscle
fatigue; a dry skin and ‘peaches and cream’ complexion; and constipation.
EXAMINATION OF THE THYROID GLAND
Although this should be part of the general examination, the method of examining the neck is
described in detail because it is so important. The
important features of the general and eye examination
are also reiterated.
Concentrate upon both the nature of any gland
enlargement or abnormal configuration, as well as
any change in endocrine activity. It is best to assess
both aspects in a combined approach, rather than
try to assess each separately.
Look at the whole patient
First confirm that the swelling in the neck is in the thyroid gland by watching to see if it moves when the
patient swallows. Then look at the whole patient.
Are they sitting still and composed, or fidgeting
about, constantly moving their fingers and looking
nervous and agitated, or are they slow and ponderous
in their movements?
FIG 11.33 EXAMINATION OF THE THYROID GLAND.
one lump
two lumps
diffuse enlargement
Try to decide if there is:
Feel the trachea.
If one lobe is
difficult to feel,
make it more
prominent by
pressing firmly
on the opposite
side.
Listen over the gland
for a systolic bruit.
Percuss the lower limit
of the gland.
Palpate both lobes
and the isthmus with
the fingers flat.
14:22PM
Palpate the neck from
behind, with the
thumbs pushing the
head forwards to flex
the neck slightly.
4/19/05
Look at the
eyes and the
neck and ask
the patient to
swallow.
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The neck
Are they thin or fat? Where is the wasting or the
fattening? Patients with thyrotoxicosis have a generalized loss of weight, especially about the face, but
may also have localized wasting of their hands, face
and shoulder muscles.
Are they under-clothed and sweaty, or wrapped
up in a large number of jumpers but still cold?
Look at the hands
■
■
■
Feel the pulse Tachycardia suggests
thyrotoxicosis; bradycardia suggests
myxoedema. In middle-aged and elderly
patients thyrotoxicosis may cause atrial
fibrillation.
Are the palms moist and sweaty?
Is there a tremor? Test for a tremor by
asking the patient to hold their arms out in
front of them, elbows and wrists straight,
fingers straight and separated. Thyrotoxicosis
causes a fine, fast tremor. If in doubt, hold
out your own hand beside the patient’s
for comparison. A fine tremor may be
accentuated by placing a sheet of paper
over the fingers.
Normal
Examine the eyes
Eye symptoms
Patients who suffer from thyrotoxicosis may complain of staring or protruding eyes and difficulty
closing their eyelids (exophthalmos), double vision
caused by muscle weakness (ophthalmoplegia) and
swelling of the conjunctiva (chemosis). They may
get pain in the eye if the cornea ulcerates.
There are four important underlying changes
that can occur in the eyes of patients with hyperthyroidism that produce the above effects (Figs 11.34
and 11.35). Each one may be unilateral or bilateral.
Lid retraction and lid lag
This sign is caused by over-activity of the involuntary (smooth muscle) part of the levator palpebrae
superioris muscle. If the upper eyelid is higher than
normal and the lower lid is in its correct position,
the patient has lid retraction. Do not be deceived
into thinking this abnormality is caused by exophthalmos.
When the upper lid does not keep pace with the
eyeball as it follows a finger moving from above
downwards, the patient has lid lag.
Upper lid halfway between pupil
and superior limbus
Lower lid at a tangent to inferior limbus
Lid retraction
Upper lid raised
Lower lid normal
N.B. This is not
exophthalmos
Exophthalmos
Both lids moved away from centre with
sclera visible below or all round the iris
FIG 11.34 The relations of the eyelids to the iris.
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Examination of the thyroid gland
Exophthalmos but no lid retraction.
Exophthalmos.
Unilateral lid retraction.
Wasting and loss of hair (and exophthalmos).
Exophthalmos and lid retraction.
Severe lid retraction but no exophthalmos.
FIG 11.35 SOME EYE SIGNS ASSOCIATED WITH THYROTOXICOSIS.
Chemosis. The conjunctiva is hyperaemic and bulging
over the eyelid. There is exophthalmos, lid retraction
and peri-orbital oedema.
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The neck
changed. Sclera becomes visible below the lower
edge of the iris (the inferior limbus).
Because the eyes are pushed forwards, the patient
can look up without wrinkling the forehead, but
will have difficulty converging. In severe exophthalmos the patient cannot close their eyelids and
may develop corneal ulceration.
Ophthalmoplegia
Although exophthalmos stretches the eye muscles, it
does not usually affect their function. The cause of
the weakness of the ocular muscles (ophthalmoplegia) associated with severe exophthalmos is oedema
and cellular infiltration of the muscles themselves
and of the oculomotor nerves. The muscles most
often affected are the superior and lateral rectus
and inferior oblique muscles. Paralysis of these
muscles prevents the patient looking upwards and
outwards.
Chemosis
This patient had gross chemosis and exophthalmos but the
eye was pulsating. The cause of these abnormalities was a
carotid artery–cavernous sinus fistula.
Chemosis is oedema of the conjunctiva. The normal
conjunctiva is smooth and invisible. A thickened,
crinkled, oedematous and slightly opaque conjunctiva is easy to recognize.
Chemosis is caused by the obstruction of normal
venous and lymphatic drainage of the conjunctiva
by the increased retro-orbital pressure.
FIG 11.35 continued
Inspect the neck
Exophthalmos
If the eyeball is pushed forwards by an increase in
retro-orbital fat, oedema and cellular infiltration,
the normal relationship of the eyelids to the iris is
Revision panel 11.5
The eye signs of thyrotoxicosis
Lid retraction and lid lag
Exophthalmos, which also causes difficulty with
convergence and absent forehead wrinkling
when looking upwards
Ophthalmoplegia, particularly of the superior
rectus and inferior oblique muscles (cannot
look ‘up and out’)
Chemosis
After checking that the lump is in the anatomical site
of the thyroid gland, ask the patient to swallow. The
patient may need a sip of water to help deglutition.
All thyroid swellings ascend during swallowing.
Observe the general contours and surface of the
swelling. The skin may also be puckered and pulled
up by swallowing if the patient has a thyroid carcinoma which has infiltrated into the skin, although
this is uncommon.
Ask the patient to open their mouth and then to
put out their tongue. If the lump moves up as the
tongue comes out, it must be attached to the hyoid
bone, and is likely to be a thyroglossal cyst.
The neck veins will be distended if there is a mass
obstructing the thoracic inlet.
Look at the position of the thyroid cartilage. Is it
in the centre of the neck or deviated to one side?
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Different forms of goitre
Palpate the neck from the front
Auscultation
The most important part of palpation is done from
behind (see below), but it is worthwhile placing your
hand on any visible swelling while standing in front
of the patient, to confirm your visual impression of
its size, shape and surface, and to find out if it is
tender. It is sometimes helpful to measure and record
the circumference of the neck with a tape measure.
Check the position of the trachea. This is best
done by feeling with the tip of two fingers in the
suprasternal notch. The trachea should be exactly
central at this point. When a thyroid mass extends
below the suprasternal notch and obscures the
trachea, you must examine the thyroid cartilage. A
mass that is displacing the trachea will tilt the thyroid cartilage laterally.
Listen over the swelling. Thyrotoxic and vascular
glands and lumps may have a systolic bruit.
Palpate the neck from behind the
patient
Stand behind the patient. Place your thumbs on the
ligamentum nuchae and tilt the patient’s head
slightly forwards to relax the anterior neck muscles.
Let the palmar surface of your fingers rest on each
side of the neck. They will be resting on the lateral
lobes of the thyroid gland. A small lobe can be made
prominent and easier to feel by pressing firmly on
the opposite side of the neck.
Ask the patient to swallow while you are palpating the gland to confirm that any swelling moves
with swallowing and is actually part of the thyroid.
This manoeuvre also lifts up lumps that are lying
behind the sternum into the reach of your fingers.
At the end of palpation you should know the following facts about the gland and/or the lump: tenderness, shape, size, surface and consistence.
A normal thyroid gland is not palpable.
Palpate the whole of the neck for any cervical
and supraclavicular lymphadenopathy.
Percussion
Percussion is used to define the lower extent of a
swelling that extends below the suprasternal notch
by percussing along the clavicles and over the sternum
and upper chest wall. This can be done when standing in front of or behind the patient. Percussion of
the lump in the neck itself is rarely helpful.
General examination
Pay particular attention to the cardiovascular and
nervous systems for any evidence of hyperthyroidism or hypothyroidism, the signs and symptoms of which are described on pages 299–303.
DIFFERENT FORMS OF GOITRE
Simple hyperplastic goitre
Simple enlargement of the thyroid gland is invariably caused by excess stimulation by thyroid-stimulating hormone (TSH), the production of which is
stimulated by low levels of circulating thyroid hormone. Relative iodine deficiency is the commonest
pathological cause for a low level of thyroid hormone production. Physiological states that require
increased activity of the thyroid gland, such as
puberty and pregnancy, are also associated with
enlargement of the gland.
The term colloid goitre is used to describe the late
stage of diffuse hyperplasia, when all the acini are distended with colloid which has not been released
because the stimulation by TSH has dropped off.
History
Age In areas where goitre is endemic (i.e. prevalent
in the local population), hyperplastic goitres appear
in childhood.
Revision panel 11.6
Plan for the examination of a patient with a goitre
Look at the whole patient for agitation,
nervousness or lethargy.
Examine the hands for sweating, tremor,
tachycardia.
Examine the eyes for exophthalmos, lid lag,
ophthalmoplegia, chemosis.
Examine the neck: always check that the lump
moves with swallowing.
Palpate the cervical lymph glands.
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A large colloid goitre. The patient was euthyroid.
A large central solitary nodule.
A nodular goitre extending below the sternum and causing
venous obstruction. Distended veins are visible above the right
clavicle. The patient was euthyroid.
Beware! Not all lumps in the neck are thyroid swellings. This
mass was soft and did not move with swallowing. It was a
lipoma. Never make a spot diagnosis. Examine every lump
carefully and thoroughly.
FIG 11.36 VARIOUS GOITRES.
in women than in men.
Rocky Mountains, and the lowland areas that depend
upon water from mountain ranges, such as the Nile
Valley, Congo Delta and Great Lakes of the USA. The
rain that falls on the mountains has a normal iodine
content, but it is filtered out by the time it reaches the
springs and streams of the highland valleys.
Geography Endemic goitre is common in places where
the drinking water has a low iodine content, such as
the habitable valleys of the Alps, Andes, Himalayas and
Diet Some vegetables contain chemicals which are
goitrogens (i.e. they interfere with hormone synthesis). An excess dietary intake of the brassica family of
Sporadic physiological hyperplastic goitres appear
at puberty, during pregnancy, and during severe illnesses and emotional disturbances, and so they are
commonly seen in puberty and young adult life.
Sex Hyperplastic goitres are five times more common
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Different forms of goitre
Shape The swelling usually follows the configuration
of the gland and can be seen to have two lobes and
an isthmus.
Size Physiological goitres are only two or three times
larger than a normal gland, but iodine-deficiency
goitres can become very large.
Surface The surface of a hyperplastic goitre is
smooth. If it turns into a colloid goitre, its surface
becomes bosselated and, in time, nodular.
Composition The gland feels firm and is dull to per-
cussion. Hyperaemic physiological goitres may have
a very soft systolic bruit.
Relations The gland moves upon swallowing. The
other tissues in the neck should be normal.
Lymph glands The deep cervical lymph glands should
not be palpable.
The eyes The eyes should be normal.
General examination The patient is usually euthyroid.
Multinodular goitre
FIG 11.37 A large goitre causing skin changes and imminent
ulceration.
foods (e.g. cabbage, sprouts and kale) can cause a
goitre.
Local symptoms The principal complaint is of a
swelling in the neck. This appears slowly and without pain.
If it becomes large – especially if it remains as a
colloid goitre after the initial stimulus has gone – it
can cause pressure symptoms such as dyspnoea,
venous engorgement and mild discomfort during
swallowing.
General symptoms Diffuse hyperplastic goitres are not
usually associated with clinically significant hyperfunction or hypofunction of the gland.
Long-standing colloid goitres often become nodular goitres and occasionally secondary thyrotoxicosis
(Plummer’s syndrome) or myxoedema may develop.
Examination
Position The swelling occupies the anatomical site of
the thyroid gland.
Tenderness It is not tender.
Multinodular goitres develop spontaneously and
in glands subjected to prolonged stimulation (i.e.
hyperplastic glands). They can therefore be endemic
(in iodine-deficient areas) or sporadic (occurring
haphazardly).
A nodular goitre results from a disorganized response of the gland to stimulation, and contains areas
of hyperplasia and hypoplasia, side by side.
The cut surface of a nodular goitre reveals nodules
with haemorrhagic, necrotic centres, separated by
normal tissue. The normal tissue contains normally
active follicles; the nodules contain both hyperactive and degenerate, involuting, follicles.
When the nodules are hyperplastic the patient
may develop secondary thyrotoxicosis.
In long-standing nodular goitres, most of the nodules are inactive and the quantity of normally active
follicles may be so reduced that thyroid hormone
production is inadequate and myxoedema develops.
History
Age In endemic areas, nodular goitres appear in early
adult life (15–30 years). Sporadic nodular goitres
appear later, between the ages of 25 and 40 years.
Sex Nodular goitres are six times more common in
women than in men.
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Geography These goitres are common in areas where
the drinking water is deficient in iodine (see hyperplastic goitre).
Symptoms The commonest presenting symptom is
an enlarging, painless swelling in the neck, which
may cause dyspnoea, discomfort when swallowing, stridor and engorged neck veins.
Sudden enlargement and pain can occur if there
is haemorrhage into a necrotic nodule. Necrotic
nodules are not cysts, and it is wrong to call this
event a haemorrhage into a cyst.
Thyrotoxicosis occurs in a significant proportion
(maybe as high as 25 per cent) of patients with longstanding nodular goitres. The symptoms of thyrotoxicosis are listed on pages 299–300.
Myxoedema: as the follicular hyperplasia and its
stimulation subside, the patient is left with a devastated gland that has little normal tissue. Ultimately, its
endocrine secretions are inadequate and the patient
has a considerable chance of becoming myxoedematous by the time they reach 60 or 70 years of age.
The symptoms of myxoedema are described on
pages 301–2.
Examination
Position The swelling is in the lower third of the
neck in the anatomical site of the thyroid gland and
is usually asymmetrical.
Tenderness A nodular goitre is only tender when
there has been a recent haemorrhage into a nodule.
Shape and size The nodules are asymmetrical and
the gland can become any shape. Nodules in the
isthmus are prominent. The nodules may extend
below the clavicles and the sternal notch, into the
superior mediastinum.
Surface The surface of a nodular goitre is smooth
but nodular. Frequently, only one nodule may be
Revision panel 11.7
Causes of a ‘solitary’ nodule in the thyroid gland
A dominant nodule in a multinodular goitre
Haemorrhage into a nodule
Adenoma
Carcinoma (papillary or follicular)
Enlargement of the whole of one lobe (usually
Hashimoto’s disease)
palpable, even though the rest of the gland is
grossly diseased. This is termed a ‘dominant nodule’
and malignancy must be excluded.
Composition The consistence of the nodules varies:
some feel hard, others feel soft. There is an old saying
that ‘Solid lumps in the thyroid feel cystic, whereas
cystic lumps feel solid’. The explanation is that a
nodule composed of thyroid tissue is soft, whereas a
nodule full of blood and liquefied necrotic tissue
becomes tense and feels hard.
The nodules of a nodular goitre do not fluctuate,
or transilluminate, and are dull to percussion.
There should be no bruit over the gland.
Relations The lump will move upwards during swal-
lowing, indicating that it is fixed to the trachea. It
should not be fixed to any other nearby structures.
Lymph drainage The cervical lymph glands should
not be palpable.
State of local tissues The trachea may be compressed
and/or deviated, depending on the site of the nodules. Bilateral nodules will compress the trachea
into a narrow slit, causing dyspnoea and stridor –
especially during lateral flexion of the neck. Large
unilateral nodules will push the trachea laterally.
When the trachea is pushed to one side, the ‘keel’
of the larynx is tilted away from the mid-line.
If the gland is jammed in the thoracic inlet, it
may obstruct and distend the jugular veins.
Rarely, the goitre is so large that it starts to cause
pressure on the overlying skin, and on occasions
may even start to ulcerate through.
The eyes The eyes should be normal. It is unusual to
get neurological or eye changes with secondary thyrotoxicosis associated with a nodular goitre. These systems are affected more often in primary thyrotoxicosis.
General examination There may be the general signs
of thyrotoxicosis – especially the cardiovascular
signs or, in elderly patients with very long-standing
nodular goitres, the signs of myxoedema.
The solitary nodule
Although only one nodule may be palpable, approximately one-half of the patients who present with
a solitary nodule actually have a multinodular
goitre, i.e. a clinically dominant nodule in a macroscopical multinodular goitre.
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Thyrotoxicosis and myxoedema
It is unusual to be able to determine the pathology
of a solitary nodule by clinical examination. Thus,
although the majority of solitary nodules are benign,
they must all be investigated, as many well-differentiated carcinomata of the thyroid present as solitary
nodules. Fine-needle aspiration (FNA) to determine
the cytology of the nodule has become part of the
routine of clinical examination in many clinics.
Thyrotoxicosis caused by a solitary toxic/autonomous adenoma is uncommon and is never (well,
hardly ever) caused by a solitary malignant nodule.
The causes of a solitary nodule in the thyroid
gland are:
■
■
■
■
■
dominant nodule in a multinodular goitre,
haemorrhage into, or necrosis of, a hyperplastic
nodule,
adenoma,
carcinoma (papillary or follicular),
enlargement of the whole of one lobe by
thyroiditis.
The increased tissue metabolism causes an
increased appetite, a decrease in weight and an
increased heat production.
The increased adrenergic receptor sensitivity
causes tachycardia, extrasystoles, atrial fibrillation,
tremor and nervousness, and lid retraction and lid lag.
Stimulation of growth during childhood produces early maturation and a slight increase in the
rate of growth.
In myxoedema (hypothyroidism), all of these
symptoms are reversed. The lack of growth stimulation in a child causes dwarfism.
History
Age Primary thyrotoxicosis occurs most often in
young women, between 15 and 45 years of age.
Toxic autonomous nodules can occur at any age.
Secondary thyrotoxicosis (from a nodular goitre)
occurs in middle age – between 45 and 65 years.
Sex Primary thyrotoxicosis is ten times more com-
mon in women than in men.
THYROTOXICOSIS AND MYXOEDEMA
Geography Secondary thyrotoxicosis is more com-
(Hyperthyroidism and hypothyroidism)
mon in those areas where simple hyperplastic goitre
(and nodular goiter) is endemic.
Thyrotoxicosis
Metabolic symptoms The patient complains of a rav-
Thyrotoxicosis is caused by an excess of circulating
thyroid hormone. The gland may be diffusely hyperplastic (Graves’ thyroiditis), nodular, or the site of
disease such as thyroiditis or an adenoma, but rarely
a carcinoma.
The terms ‘primary’ and ‘secondary’ are used to
describe thyrotoxicosis arising in a previously normal
or previously abnormal gland, respectively. They can
be confusing terms, but usually primary thyrotoxicosis (Graves’ disease) is caused by a form of autoimmune thyroiditis, whereas secondary thyrotoxicosis
(Plummer’s syndrome) usually occurs in a longstanding multinodular goitre.
The thyroid hormones tri-iodothyronine (T3)
and thyroxine (T4) have three effects.
1. They increase the metabolic rate of all cells.
2. They increase the sensitivity of beta-adrenergic
receptors.
3. They stimulate all cells to grow, but the effect on
growth is only significant before natural growth
has finished.
enous appetite, but in spite of eating excessively,
tends to lose weight. Patients may also find that
they always feel warm, and therefore like cold
weather and dislike hot weather. There may be
excessive sweating.
Cardiovascular symptoms The patient complains of pal-
pitations, shortness of breath during exertion,
missed and irregular heart beats (extrasystoles and
atrial fibrillation) and tiredness. Cardiovascular symptoms are often the presenting symptoms of secondary thyrotoxicosis, whereas atrial fibrillation may be
the only sign of thyrotoxicosis in an elderly patient.
Neurological symptoms Symptoms such as nervousness,
irritability, insomnia, depression and excitement,
even mania and melancholia, may be noticed by close
relatives long before the patient is aware of them.
There may be hyperaesthesia, headaches, vertigo
and tremors of the hands and tongue.
The patient may complain that their eyes have
become more protuberant and that some eye movements are difficult.
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A nodular goitre. No eye or nervous system signs, but
palpitations, breathlessness and atrial fibrillation.
Alimentary symptoms The changes in appetite and
A small goitre, nervousness and agitation, beginning to lose
weight, left lid retraction and very early exophthalmos (sclera
visible below right inferior limbus).
weight have been mentioned under metabolic
symptoms. There is often a slight change in bowel
habit – usually mild diarrhoea.
Genital tract symptoms Most women have a reduction in
the quantity of their menses; some have amenorrhoea.
Musculoskeletal symptoms In addition to generalized
weight loss, there may be specific wasting and weakness of the small muscles of the hand, shoulder
and face. These muscles rarely become completely
paralysed.
Cause Patients with primary thyrotoxicosis may
relate the onset of their symptoms to puberty, pregnancy, an illness or a sudden emotional upset.
Although it is difficult to be certain that events of
this sort are the prime cause of hypersecretion of
the thyroid gland, they undoubtedly exacerbate any
hidden or developing abnormality. They are sometimes remembered as the three Ss – sex (puberty
and pregnancy), sepsis and psyche!
Examination
Signs in the neck
A large goitre, increasing appetite but weight loss –
particularly of the face and shoulder girdle – no eye signs.
FIG 11.38 THE FACIES OF THYROTOXICOSIS.
The thyroid gland is usually enlarged, but thyrotoxicosis can be present without any enlargement of
the gland.
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Thyrotoxicosis and myxoedema
The enlargement may be diffuse, nodular or tender, depending on the local pathology.
A diffusely enlarged hyperaemic gland usually
has a systolic bruit audible over its lateral lobes.
METABOLIC SIGNS
Signs in the eye
CARDIOVASCULAR SIGNS
Thyrotoxicosis is associated with four groups of
physical signs in the eyes.
LID RETRACTION AND LID LAG
These are common signs. In lid retraction the upper
eyelid crosses the eye above its usual level (mid-way
between the pupil and the superior limbus of the
iris) because the autonomic part of the levator
palpebrae superioris muscle is hypertonic.
Ask the patient to follow your finger as you move
it slowly from above downwards. If the upper eyelid
does not keep pace with the eye, the patient has lid
lag. This is also caused by the increased tone of the
levator palpebrae superioris muscle.
The patient may blink less frequently than normal.
The patient looks thin and their face and hands may
be particularly wasted. They may look hot and be
sweating, even in a cold room.
There is usually a tachycardia of 90 beats/minute or
more at rest, which persists during sleep.
If there are extrasystoles or atrial fibrillation,
the pulse will be irregular.
If there is mild heart failure, there may be râles at
the bases of the lungs and oedema of the ankles.
NEUROLOGICAL SIGNS
The patient looks worried and nervous and moves
about in an agitated, jerky way. They will often twist
and twine a handkerchief between their fingers.
A fine tremor may be demonstrated when they
stretch out their hands with their fingers spread. A
similar tremor may be present in the protruded
tongue.
MUSCULOSKELETAL SIGNS
EXOPHTHALMOS
Oedema of the retro-orbital tissues pushes the
eye forwards. The first abnormality is the appearance of sclera below the inferior limbus, but when
the condition is extreme, the eye appears to be popping out and the eyelids cannot be completely
closed.
Exophthalmos makes convergence difficult and
allows the patient to look up without raising their
eyebrows or wrinkling their forehead. Corneal ulceration may complicate severe exophthalmos.
OPHTHALMOPLEGIA
Infiltration of the ocular muscles weakens the eye
muscles and diminishes the eye movements. The
muscles most often affected are the superior rectus
and inferior oblique muscles. As these muscles
normally turn the eye upwards and outwards, this is
the first movement to become weak.
The muscles of the hands, shoulders and face may
be wasted and weak and the finger tips enlarged.
SKIN
In certain patients with Graves’ disease, red, blotchy,
raised areas may be seen over the shins. This is termed
pretibial myxoedema and is caused by deposits of
myxoid tissue within the skin.
Myxoedema
History
Myxoedema is the clinical state which follows a
severe lack of thyroid hormone (hypothyroidism).
The term means ‘mucous swelling’ and is used
because when it was first described it was believed
that the increase in weight and body swelling was
caused by a new form of oedema.
Age Myxoedema tends to occur in middle and old age.
CHEMOSIS
Sex It is more common in women than in men.
This is oedema of the conjunctiva. The conjunctiva
becomes thick, boggy and crinkled and may bulge
over the eyelids. The eyes water excessively.
Metabolic symptoms The patient complains of tiredness and weakness, which become intense physical
and mental lethargy.
The patient always feels cold, and therefore likes
hot weather and dislikes cold weather. They gain
weight but have a poor appetite.
General signs
These are best described in bodily systems.
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Cardiovascular symptoms Breathlessness and ankle
swelling indicate the onset of cardiac failure.
Neurological symptoms The patient finds it difficult to
think and to speak quickly and clearly. Hallucinations,
dementia (‘myxoedema madness’) and, in severe
cases, ‘myxoedema coma’ can occur.
Alimentary symptoms Progressive and obdurate consti-
pation is common.
Genital tract symptoms Menorrhagia is common when
myxoedema occurs before the menopause.
Examination
Signs in the neck
FIG 11.39 The facies of myxoedema. Thinning of the hair, loss
of the outer third of the eyebrows, ‘peaches and cream’
complexion, thickening and heaviness of the eyelids.
The thyroid gland may be enlarged by long-standing disease such as a nodular goitre, but in many
cases the neck is normal.
Signs in the eyes
The eyes are normal but the eyelids become swollen
and heavy, making the patient look sleepy and
lethargic.
The hair of the outer third of the eyebrows falls out.
General signs
General appearance and metabolic signs The complex-
ion of a white-skinned patient with myxoedema is
said to resemble peaches and cream. The skin is
smooth and has a pale-yellow (the cream) colour.
The cheeks are often slightly flushed and have a
pink-orange tinge (the peaches).
The skin is dry and inelastic and does not sweat.
Although it may look oedematous, it does not pit
after prolonged pressure.
The patient is overweight, with excess connective
tissue and fat in the supraclavicular fossae, across
the back of the neck and over the shoulders.
The hair looks thin and ragged and falls out.
The hands are puffy and spade-like.
The tongue enlarges and seems to fill the mouth
during speech and interfere with the articulation of
words. The voice becomes deep and hoarse.
FIG 11.40 Pretibial myxoedema.
Cardiovascular signs The pulse rate is slow (40–60 beats/
minute) and the blood pressure is low. Both these
changes may be reversed if heart failure develops.
The hands are cold and the finger tips blue.
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Carcinoma of the thyroid gland
Neurological signs Mental alertness and the ability
to respond to questions and solve problems are
noticeably retarded. Conversation is also hampered
by the difficulty in articulation caused by enlargement
of the tongue.
All movements are slow and deliberate.
The reflexes are sluggish and their relaxation
period prolonged.
Cretinism
A cretin is a child whose mental and physical development has been retarded by a lack of thyroid hormone. Nowadays cretins are rare because the
hormone deficiency can be replaced.
Cretinism is likely to occur in those places where
goitre is endemic. The child may have a goitre.
The cretin has an underdeveloped skeleton (a
dwarf) and a large protruding tongue, the eyes are
wide apart, and the skull is also wide. The limbs and
neck are short and the hands spade-like.
The skin is dry and there are supraclavicular
pads of fat.
The abdomen is distended and protuberant and
there is often an umbilical hernia.
There is mental retardation, even imbecility.
When hypothyroidism occurs in older children,
they develop a mixture of the symptoms of cretinism and myxoedema.
CARCINOMA OF THE THYROID
GLAND
The thyroid gland is a very vascular organ, and secondary tumour deposits from primary lesions in
the breast, stomach, colon and lung are often found
at autopsy. However, these secondary deposits rarely
become large and noticeable and rarely present
Revision panel 11.8
Correlation between clinical state of the thyroid gland, endocrine function and
pathological diagnosis
Hypothyroid
Euthyroid
Hyperthyroid
Diffuse enlargement
Thyroiditis
Primary hyperthyroidism
(Graves’ disease)
Multinodular
enlargement
Multinodular goitre
with gross
degeneration
Solitary nodule
Coincidental nodule
with myxoedema
No palpable goitre
Thyroiditis
Primary myxoedema
Post-thyroidectomy or
post-radioactive iodine
Iodine deficiency
Enzyme defects
Goitrogens
Thyroiditis
Amyloid
Physiological
(pregnancy, puberty)
Multinodular goitre
Lymphoma
Anaplastic carcinoma
Medullary carcinoma
Cyst
Dominant nodule
Adenoma
Follicular or papillary
carcinoma
Normal gland
Secondary
hyperthyroidism
(Plummer’s syndrome)
Autonomous toxic
nodule
Primary hyperthyroidism
Thyroxine overdose
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primarily as a thyroid swelling. The majority of the
neoplasms in the thyroid gland that present as a
lump in the neck are primary thyroid tumours.
There are three varieties of carcinoma of the thyroid follicles:
Duration of symptoms The lump may have been present for many years before the patient seeks advice,
because these tumours are slow growing and slow to
spread beyond the thyroid gland and its draining
lymph glands.
■
■
■
Cause The patient will have no idea of the cause of
papillary carcinoma
follicular carcinoma
anaplastic carcinoma.
The parafollicular (C) cells can also undergo
malignant change, and this cancer is called:
■
medullary carcinoma.
The lymphoid tissue in the gland can also undergo
malignant change to become a lymphoma, but this
is not a true thyroid tissue neoplasm. Lymphoma is
more common in patients with Hashimoto’s disease.
Papillary carcinoma
This tumour contains a few formed follicles, but its
bulk consists of hyperplastic follicular epithelium
with a papilliferous configuration which sometimes
produces a small quantity of colloid. This tumour
spreads in the lymphatics. The cervical lymph
glands may be palpable long before the primary
lesion in the thyroid gland becomes palpable.
History
Age Papillary carcinoma is a tumour of children
and young adults. Because it occurs in young children, the metastases in the lymph glands were once
thought to be clusters of aberrant normal thyroid
tissue. They are not. They are true metastases and
may often be the presenting feature. Often these
enlarged nodes can present as large cystic swellings
and mimic a branchial cyst.
Sex Females are affected three to four times more
often than males.
Symptoms The common presenting symptom is a
lump in the neck. The lump may be in the region of
the thyroid gland or, if it is caused by secondary
deposits in the lymph glands, in the antero-lateral
part of the neck.
Distant secondary deposits or a change in thyroid function are very uncommon with papillary
carcinomata.
the lump, but it is important to ask them if they
have had any radiation to the neck or mediastinum.
There is a greater incidence of papillary carcinoma
in children who have had their neck or chest intentionally irradiated for conditions such as asthma,
tuberculosis, enlargement of the thymus, tonsillitis
and acne (a form of treatment no longer practised),
and unintentionally following a nuclear reactor
accident.
Examination
The principal, and usually the only, abnormality is
the lump or lumps in the neck.
Position The lump may be in the region of the thyroid gland or deep to the sternomastoid muscle.
Temperature and tenderness The skin of the neck
should be normal, provided the tumour has not
infiltrated into it. The lumps are usually not tender.
Shape and size The primary nodule in the thyroid
gland may vary in size from a minute, impalpable
nodule to a nodule 3–5 cm in diameter. When palpable, it is usually spherical, smooth and clearly
defined, but its surface may be bosselated.
Lymph glands containing thyroid carcinoma
metastases are ovoid or nodular, and usually
smooth and clearly defined. Occasionally they can
be cystic, providing a diagnostic dilemma. The thyroid gland lymph first drains to the pretracheal and
paratracheal lymph glands and then to the lower
deep cervical lymph glands which lie beneath the
anterior edge of the lower third of the sternomastoid
muscle.
Composition The consistence of both the primary
nodule and the secondary lymph glands is hard or
firm. Both are dull to percussion, do not fluctuate
and do not cause a bruit.
Relations The primary nodule in the thyroid gland
will move upon swallowing and is not usually fixed
to superficial structures.
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Carcinoma of the thyroid gland
capsule and has spread into the substance of the
gland – the ‘invasive’ variety of follicular carcinoma.
Multiple lumps in the neck caused by metastases in lymph glands do occur, but not as frequently as with papillary carcinoma.
Systemic effects These patients are euthyroid.
Examination
The principal, and often the only, abnormality is the
lump in the neck.
FIG 11.41 A poorly differentiated follicular carcinoma arising
in a long-standing multinodular goitre.
Enlarged lymph glands move more easily in a transverse than in a vertical plane and do not move with
swallowing. They are not usually attached to the skin.
Lymph drainage If you feel a nodule in the thyroid
gland, examine all the lymph glands in the neck
with care.
General examination The patient usually appears fit and
well, without any of the systemic signs which suggest
a disseminated neoplasm or thyroid dysfunction.
Position Follicular carcinoma usually arises in one of
the lateral lobes of the thyroid gland.
Temperature and tenderness The overlying skin is not
hot and the lump is not tender.
Shape and size The lump is usually spherical and
smooth, with distinct edges. Even the invasive variety feels as if it has a distinct surface.
Composition The lump is firm to hard, does not fluc-
tuate, is dull to percussion and has no bruit.
Relations The lump moves with swallowing, but is
not attached to overlying structures.
Lymph glands The deep cervical lymph glands may
Follicular carcinoma
The cells in this well-differentiated thyroid cancer
retain their normal follicular configuration. Most of
the follicles contain a small amount of colloid, which
implies that the cells are synthesizing hormone. This
has an important bearing on treatment, because the
tumour cells will often take up radioactive iodine.
This tumour spreads by the bloodstream.
History
Age Follicular carcinomata occur in adults between
be enlarged and hard.
Local tissues The local tissues are usually normal.
General examination Examine the chest carefully for
any evidence of consolidation or collapse. Pulmonary
secondary deposits are quite common but may not
cause any abnormal physical signs.
Metastases in the skeleton are often painful and
tender. A bone near to the skin containing a metastasis may be visibly deformed, swollen and hot. Some
thyroid cancer metastases are so vascular that they
are soft and pulsatile and have an audible bruit.
the ages of 20 and 50 years.
Sex Women are affected more often than men.
Anaplastic carcinoma
Symptoms The common presenting symptom is a
lump in the neck, which may have been present for
many years.
If the tumour has spread beyond the thyroid, the
patient may complain of breathlessness, chest pain or
pain or swelling in a bone, caused by lung and bone
metastases, respectively. In these circumstances the
pathologist usually finds that the tumour has a thin
This is the worst variety of thyroid cancer because it
spreads rapidly. Most patients with this disease are
dead within 1 year of diagnosis. Its cells do not
synthesize thyroid hormone.
History
Age Anaplastic carcinoma of the thyroid gland
appears between the ages of 60 and 80 years.
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The neck
grows quickly and is highly invasive. Local invasion
and compression of the trachea can lead to death
from asphyxia or precipitate a fatal pneumonia.
Examination
Position The swelling in the neck is in the region of
the thyroid gland. At first this is in one lobe, but in
advanced cases the whole gland may be enlarged
and irregular.
Colour The overlying skin often has a red-blue tinge
because the underlying infiltration interferes with
its venous drainage.
Temperature The skin temperature is normal, or
slightly raised.
Tenderness The mass often becomes tender as the
tumour infiltrates beyond the thyroid gland.
Shape The mass in the neck has no definable shape
once it has spread beyond the thyroid gland, and
before this stage it is not easy to define because the
surface is so indistinct.
FIG 11.42 An anaplastic carcinoma of the thyroid.
Size The mass may become so big that it interferes
with neck movements.
Sex Females are affected more often than males.
Surface and edge The surface is irregular and indis-
Symptoms The common complaint is a swelling of
tinct and the lump often has no palpable edge.
the neck rather than ‘a lump’, which may be rapidly
growing. The patient complains of swelling because
the tumour is diffuse and infiltrating, not localized.
A dull aching pain in the neck is quite common.
Dyspnoea occurs when the tumour begins to
compress the trachea, especially when the neck is
flexed. It may also occur if there are multiple pulmonary metastases.
Hoarseness or a change in the quality of the
voice is a diagnostic symptom because it implies
infiltration of the recurrent laryngeal nerve.
Pain in the ear, caused by infiltration of the
vagus nerve, is not uncommon.
There may be bone pain. Any bone can be the
site of a secondary deposit, and pathological fractures can occur.
General malaise and weight loss appear when
there is disseminated disease.
Composition The mass is hard and solid. It does not
Duration of symptoms The symptoms of an anaplastic
carcinoma often develop rapidly as this carcinoma
fluctuate, is dull to percussion and has no bruit.
Relations Provided the mass is not infiltrating the
whole neck, it will move during swallowing.
It may be fixed to one or both sternomastoid
muscles and the overlying skin as well as to the trachea. When the sternomastoid muscle is contracted,
the movement of the lump during swallowing is
limited and the skin becomes puckered.
The skin may be infiltrated with tumour, making
it thick, nodular and a reddish-brown colour.
Lymph glands Although the deep cervical lymph
glands are invariably involved in the disease, their
enlargement may be obscured by the primary mass
in the gland.
If the local lymph glands are palpable, they feel
hard and fixed. At first they are smooth and discrete,
but they become irregular and indistinct when the
tumour begins to spread through their capsules.
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nature. When the condition occurs in young adults
(20–30 years), often with a family history, it may be
a manifestation of the multiple endocrine neoplasia
syndrome (MEN) types 2a or 2b.
In these cases, the medullary thyroid carcinoma may be accompanied by associated conditions
such as:
■
■
phaeochromocytoma
parathyroid tumours
其
phaeochromocytoma
neuromata of the tongue,
lips and conjuctiva
pale-brown birthmarks
megacolon
marfanoid habitus.
冧
MEN 2a
or
FIG 11.43 Tongue neuromata in a patient with MEN 2b and
medullary carcinoma of the thyroid.
State of local tissues The skin of the neck may be
tethered or fixed to the lump or even infiltrated with
tumour.
The trachea is often compressed and deviated,
causing stridor.
One vocal cord may be paralysed by infiltration
of the recurrent laryngeal nerve. This may be suspected if the patient has a hoarse voice, but must be
confirmed by indirect laryngoscopy.
All the soft tissues of the neck may be fixed and
hardened by infiltrating tumour.
General examination Patients often breathe with diffi-
culty and have stridor. There may be basal pneumonia
or collapse caused by pulmonary secondary deposits
or the restriction of lung expansion by the narrowed
trachea.
There is often wasting and anaemia.
There may be evidence of skeletal metastases –
even pathological fractures.
In advanced cases the liver may be enlarged, and
secondary deposits occasionally appear in the skin.
Medullary carcinoma
This is a rare condition but is mentioned because it
can sometimes be diagnosed before operation. It is a
neoplasm of the parafollicular (C) cells.
The common presentation is a firm, smooth and
distinct lump in the neck, indistinguishable from
any other form of thyroid solitary nodule.
The majority of patients are between the ages of
50 and 70 years when the tumour is sporadic in
■
■
■
■
■
MEN 2b
The symptoms which should make you think of
medullary tumour, apart from a lump in the neck
and the presence of the above lesions in the patient
or their family, are diarrhoea and flushing.
Diarrhoea occurs in one-third of the patients. The
fluidity of the stool and the frequency of defaecation are both increased.
If this tumour is suspected, it is important to
measure the serum calcitonin level.
THYROIDITIS
There are three varieties of thyroiditis which can
be diagnosed clinically: Hashimoto’s disease, de
Quervain’s thyroiditis and Riedel’s thyroiditis.
The term thyroiditis is a non-specific description
of the histological changes occurring in the gland.
Although the aetiology of these conditions is only
partly understood, the eponyms are useful because
they do not imply an aetiology but rather a clinical
description (provided you ignore the aetiologies proposed by the three gentlemen who made the original
descriptions!).
Hashimoto’s disease
This is an autoimmune thyroiditis. The body fails to
recognize part of itself – in this case both the mitochondria of the thyroid cells and the thyroglobulin
they produce – and sets up an immune response
against its own tissues. The result is lymphocyte and
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The neck
plasma cell infiltration of the gland that ultimately
destroys the thyroid cells. In the first instance the
thyroid cells respond by becoming hyperplastic,
causing a degree of thyrotoxicosis, but eventually
and inevitably the gradual destruction of the thyroid cells causes myxoedema (hypothyroidism).
When one lobe or more is involved, the swelling is
usually lobulated.
History
edge is distinct.
Age and sex Hashimoto’s disease is most common in
Composition The swelling has the texture of firm
middle-aged women, especially those near the menopause; but it can occur in men, and at any age.
rubber. This texture is homogeneous, in spite of the
lobulated shape, which helps distinguish the
swelling from a nodular or colloid goitre.
There is no bruit.
The composition and mild tenderness are the
features most likely to alert you to the possibility of
the diagnosis.
Symptoms in the neck The patient usually complains
of a swelling or lump in the neck. This lump may
appear gradually or rapidly, and is often painful,
particularly when it appears rapidly.
The swelling, or lump, fluctuates in size, and the
pain is often intermittent. The symptoms are worse
when the patient is tired, or run down, or has an
intercurrent illness.
The voice should not alter.
Systemic effects The symptoms of mild thyrotoxico-
sis or myxoedema may be present.
The common course of events is for the mild
symptoms of thyrotoxicosis, which appear at the
onset of the disease, to die out gradually and become
replaced by the opposite symptoms of myxoedema.
The majority of patients are euthyroid when they
complain of the lump, having ignored or not had
any symptoms of thyrotoxicosis, and not reached
the myxoedematous phase.
This variability of the local and systemic effects
of the disease makes the diagnosis difficult.
Family history Other members of the family may have
suffered from the same or other forms of autoimmune disease, such as pernicious anaemia and
autoimmune gastritis.
Examination
The main complaint is usually the lump in the neck.
Position The swelling is in the region of the thyroid
gland and may be unilateral or bilateral.
Temperature In the initial acute phase – if it occurs –
the overlying skin may feel warm.
Tenderness The swelling is often slightly tender.
Shape The swelling may be any shape – a solitary
nodule, the whole of one lobe, or the whole gland.
Size Hashimoto’s disease usually causes a moderate
swelling of the gland, easily visible but rarely gross.
Surface The swelling has a smooth surface and the
Relations The swelling moves with swallowing but is
not fixed to any other structures.
Local tissues All the local tissues should be normal.
Lymph glands The nearby lymph glands should not
be enlarged.
General examination The majority of patients are
euthyroid, but some will have the signs of mild thyrotoxicosis and others of early myxoedema.
De Quervain’s thyroiditis
This condition is a true subacute inflammation of
the thyroid gland, often associated with mild hyperthyroidism. It may be caused by a virus infection,
and sometimes occurs in epidemics.
History
De Quervain’s thyroiditis occurs in adults. The main
complaint is of the sudden appearance of a painful
swelling in the neck. The patient feels ill and may
notice that they are anxious, sweaty and hungry and
have palpitations.
Examination
Examination reveals a diffuse, firm, tender swelling
of the whole of the thyroid gland.
There may be signs of mild thyrotoxicosis –
nervousness and agitation, lid lag and tachycardia.
De Quervain’s thyroiditis is self-limiting. It disappears in 1–3 months.
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Thyroiditis
Riedel’s thyroiditis
This is a very rare condition but is mentioned
because the changes in the gland can be mistaken
for the signs of a carcinoma.
It is a condition in which the gland is gradually
replaced by dense fibrous tissue, which may even infiltrate beyond the gland into the nearby strap muscles.
The patient complains of a lump in the neck or,
very rarely, increasing dyspnoea caused by compression of the trachea.
Examination reveals a stony hard swelling of the
thyroid gland, at first of one lobe, but eventually of
both lobes and the isthmus.
The lump moves with swallowing but may be
fixed to the surrounding tissues, which are otherwise normal.
When both lobes are involved, the smooth, discrete
surface usually excludes the diagnosis of carcinoma,
but when one lobe is involved it is impossible to
make a firm clinical diagnosis.
Note
A scheme for diagnosing thyroid swellings is shown
in Figure 11.44 on pages 310–11.
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The neck
A SCHEME FOR THE DIAGNOSIS OF THYROID SWELLINGS
Once you have examined the patient you should be able to draw conclusions as to the nature and texture of the gland and as
to its endocrine activity.
The gland
1. Solitary palpable nodule
2. Multinodular goitre
3. Diffusely enlarged gland
Activity of the gland
1. Normal (euthyroid)
2. Hypersecretion (hyperthyroidism/thyrotoxicosis)
3. Hyposecretion (hypothyroidism/myxoedema)
Having established the configuration of the gland and its endocrine activity, a table can be drawn up as to possible
differential diagnoses (see Revision panel 11.8 on page 303). This allows a degree of clarity in interpreting the presenting
clinical features and in arriving at a working diagnosis.
If only one lump is palpable it may be:
The only palpable nodule of a
multinodular goitre
A benign adenoma
FIG 11.44
A cyst
Carcinoma (papillary, follicula or medullary).
The lymph glands may be palpable,
especially with the papillary type
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Thyroiditis
If more than one lump is palpable the swelling may be:
The whole of one lobe involved by
Hashimoto's thyroiditis
A multinodular goitre
An anaplastic carcinoma
especially if the voice is
hoarse and the mass is fixed
to the surrounding tissues
If there is diffuse, homogeneous enlargement of the whole gland the swellling may be:
Grave's disease. Primary thyrotoxicosis.
Slight to moderate enlargement.
Soft, smooth with a bruit
Thyroiditis. Hashimoto's,
de Quervain's or Riedel's.
Moderate or small. Hard, tender
FIG 11.44 continued
Hyperplastic (colloid) goitre.
Moderate to gross enlargement.
Bosselated. No bruit
Multifocal carcinoma
311